Ready for policy? Stakeholder attitudes toward menu labelling in Toronto, Canada.

Mah, Catherine L. ; Vanderlinden, Loren ; Mamatis, Dia 等

Menu labelling has been recommended as a policy intervention that could help to improve the availability and visibility of healthful foods when dining out. (1-3) Menu labelling applies food-labelling principles to the eating-out environment through disclosure of nutrient content of food items on menus at the point of sale. People are eating away from home more often than ever before, a trend associated with reduced dietary quality. (4-7) It has been suggested that menu labelling promotes informed food purchasing and consumption decisions through provision of clear and accessible facts about foods and beverages when they are being ordered. (8,9) While menu-labelling legislation has been adopted in several localities and states in the United States, with a subsequent federal provision, (10) no mandatory menu labelling currently exists in Canada. Emerging evidence from US jurisdictions has indicated that menu labelling can influence consumer practices; in New York City, which has had the longest experience with menu-labelling legislation, menu labelling has made nutrition information readily visible by a majority of restaurant patrons (11-13) and can influence some individuals to reduce their calorie intake. (11,13,14) Menu labelling has garnered support from advocates, (15) members of provincial parliament, (16) and expert working groups, (17,18) who have endorsed mandatory menu labelling as a policy option. Moreover, menu labelling has been deemed legally feasible and all levels of government have been identified as likely having jurisdiction to enact menu-labelling legislation in Canada. (19) Voluntary programs such as British Columbia's Informed Dining intervention have proceeded, (20) even while a Federal/Provincial/Territorial Task Group on Provision of Nutrition Information in Restaurants and Foodservices continues deliberations on a federal policy recommendation. In this environment, municipal jurisdictions will also face pressure to act decisively on nutrition information disclosure interventions.

The objective of this study was to assess key stakeholder attitudes regarding menu labelling in Toronto, as part of background research by Toronto Public Health (TPH) for a policy initiative on menu labelling for the city. Toronto is the largest municipal jurisdiction in Canada, home to 2.6 million people across 44 wards. The city is highly diverse; half of Toronto's residents were born outside Canada and this is reflected in the city's restaurant industry, which includes a wide array of cuisines and food preparation styles and nearly 6,000 independent restaurants (quick-service and sit-down).

METHODS

Staff across three directorates of TPH (Healthy Public Policy, Chronic Disease and Injury Prevention, and Healthy Environments) worked in collaboration with an academic partner to collect and analyze all data in late 2011 to early 2012.

Public survey

A consumer eating-out module was constructed using seven questions adapted from validated Canadian (4) and US surveys. (21) The module was incorporated into the 2011 Toronto Health Survey, a population health surveillance survey of Toronto residents commissioned by TPH and carried out by a market research firm. There were 1,699 respondents interviewed between October 2011 and March 2012, including a core sample of 1,200 adults 18 years of age and over, as well as an oversample of 499 youth and young adults aged 18-34. The core sample was derived through a random sample of telephone numbers, and one adult in the household was selected based on the next-birthday method. All interviews were conducted in English. The response rates for the core sample and the oversample were 26% and 66%, respectively.

Respondents were asked how often they ate out in the past week at restaurants (described as "not fast food or drive through") and fast-food outlets (described as "fast food like pizza, fried chicken, or hamburgers and french fries"), and on a Likert scale, the importance of getting "nutritious food" when eating out (very important, somewhat important, not important) as well as their current and intended use of nutrition information when eating out (always, often, sometimes, rarely, never). The prevalence of the outcomes of interest was examined using Stata, version 11.1. Bivariate chisquare tests were also run to examine the socio-demographic factors (i.e., sex, age, education, household income) associated with the outcomes of interest. Corresponding proportions, 95% confidence intervals, and p-values from the chi-square tests were calculated. All analyses are weighted to account for the likelihood of selection into the survey based on household size and the age and sex distribution in Toronto in 2011.

Independent restaurant survey

TPH contracted a market research firm to administer and analyze the results from an online survey of independent restaurant operators across Toronto from December 2011 to January 2012. Once chain and franchise establishments were excluded, approximately 5,800 independent restaurants were identified from the Toronto Healthy Environments Information System (THEIS), an administrative database used by public health inspectors to document operational food safety and other inspection data; contact information for restaurants for this study was extracted ad hoc from the database in November 2011. Recruitment was carried out by mail; invitations included a link to the survey and a unique UserID and password to ensure singular responses. The survey was translated into six languages (English, French, simplified Chinese, Korean, Spanish, and Tamil) and took approximately 10 minutes to complete. A total of 256 surveys were completed (4% cooperation rate). Operators were asked 11 closed-ended questions examining interest in and readiness for a menu-labelling policy intervention in the city, and 1 general question (open-ended comment field) asking for basic business demographic information (e.g., type of restaurant, cuisine, annual revenue, average cost of a meal, number of seats, etc.); only the results of the closed-ended questions are included in this manuscript. Closed-ended questions were developed by the research team in cooperation with the market research firm and were based on key themes identified in a literature review as relevant to industry stakeholders and in early policy consultations with restaurant associations (below).

Chain and franchise interviews

In-depth key informant interviews were carried out with executives and key decision makers (e.g., Director of Marketing; VP Operations) at chain and franchise restaurants (n=9; 6 large and 3 small, including quick-service and sit-down restaurants). The objective for carrying out qualitative interviews with these individuals rather than including them in the survey was to elicit a more nuanced set of views than these companies may already have expressed in the public domain, through websites, media, or company reports, for example. The term "chain" is used here colloquially, not in industry terms. Recruitment was carried out by e-mail with telephone follow-up (3-6 contacts) using a stratified sample of 75 chains (46 large and 29 small) derived from 274 entities with more than two locations listed in THEIS. Large chains were defined as those with revenues falling in the Top 50 for the province of Ontario in the year 2011, including local chains, major multinational chains, and foodservices conglomerates.22 Large chain restaurants were emphasized in order to elicit a range of attitudes complementary to the independent restaurant survey findings. All interviews were conducted by telephone in English in February 2012 using a semi-structured interview guide. Interviews were recorded, transcribed verbatim, and analyzed for key themes by two coders; themes were peer-debriefed by three members of the research team to revise and refine codes and themes.

Policy consultation with restaurant associations

Three members of the project team carried out separate consultation meetings in August and September 2011, with e-mail follow-ups through to March 2012, with two restaurant industry associations with a dominant presence in the city: the Ontario Restaurant, Hotel, and Motel Association (ORHMA) and the Ontario Chinese Restaurant and Foodservices Association (OCRFA). Consultations were guided by a semi-structured tool to elicit opinions on menu labelling for Toronto restaurants. Handwritten notes were taken and compiled later into electronic memos. Two members of the research team identified key themes that were validated through peer debriefing.

This research has undergone institutional ethical review: Toronto Public Health (ethics review process); Centre for Addiction and Mental Health (constituted Research Ethics Board).

RESULTS

Tables 1 and 2 present sample characteristics for the Public Survey and the Independent Restaurant Survey.

Public survey

Eating out was found to be very common among respondents: 7 in 10 (71%) reported having eaten at a restaurant or at a fast-food outlet (or both) at least once in the previous week, 54% reporting having eaten at a restaurant and 47% reporting having eaten fast food. Bivariate chi-square analyses revealed that eating out at restaurants and fast-food outlets is significantly more common among men than among women (restaurants: p<0.0001; fast food: p<0.0001) and among those in the younger age groups (restaurants: p=0.0003; fast food: p<0.0001); a gradient existed by age such that the younger the age decile, the more likely to have eaten out. Those with post-secondary education were significantly more likely to have eaten at a restaurant compared with those with less education (p<0.0001); education was not significantly associated with likelihood of having eaten fast food. Higher household income was also significantly associated with the likelihood of having eaten at a restaurant (p<0.0001) and having eaten fast food (p=0.02).

The vast majority of respondents believed that getting "nutritious food" was important when eating out; over half (54%) said that it was very important, another 36%, somewhat important. When asked about their current and intended use of nutrition information, particularly if it were to be made more readily available, the majority of individuals responded positively: 69% indicated that they use nutrition information when eating out (at least sometimes) and 78% reported that they would use nutrition information (at least sometimes) if it were to become more readily available. Females were significantly more likely than males to report that they would use information if it were made available (p<0.0001), as were those in the younger age groups (p=0.004), and those with higher levels of education (p=0.01).

Independent restaurant survey

Of respondents to the online survey of independent restaurants, 72% stated that they were not interested (not very or not at all) in providing nutrition information to their customers. Six in ten (62%) felt that their ability to provide nutrition information did not affect (not at all or not very much) a customer's decision to eat at their establishment. Underlying this attitude appears to be a dominant belief that consumers already have a good idea about which foods are healthy (91% strongly or somewhat agree). Other potential associated factors appeared pragmatic; 76% strongly or somewhat agreed that adjusting menus to provide nutrition information would be an expensive undertaking, and 64% felt that they were too busy to "figure out" nutrition information provision. Sixty-two percent of respondents indicated that they would not provide nutrition information unless they absolutely had to.

However, 57% of respondents reported feeling some responsibility to provide nutrition information. Half of respondents indicated that nutrition information could be good for business, agreeing that menu labelling is a way to attract customers; 42% of respondents noted that they would be interested in being part of a pilot program.

Chain and franchise interviews

Several major themes emerged. Restaurants are clearly responsive to consumer demand, and health concerns, broadly defined, were seen to be a hot industry issue. The range of health concerns discussed by interviewees went well beyond calorie or even nutrient-specific information, however; with little prompting, interviewees discussed general health and health conditions (e.g., diabetes), health concerns among particular population groups (e.g., aging population), foods or preparations that are perceived to be "healthy" (e.g., fish or grilled items), allergies, diets (e.g., gluten-free), quality of products or standards of production (e.g., agricultural origin), and broader environmental issues (e.g., biodegradable packaging), in addition to traditional nutrient categories (e.g., calories, sodium).

Interviewees also identified a number of perceived challenges to implementing nutrition information disclosure programs, including operational issues such as recipe customization when preparing food and redesign of menu boards, but also proprietary concerns about ownership over how information is presented on menus.

Many large-chain restaurants, and some smaller chains, however, indicated that they were already providing some type of nutrition or health information to consumers. The largest chains see themselves as industry leaders in this regard, but smaller chains interviewed are also taking active steps to provide services. Nearly all interviewees noted that they had taken health concerns into account to reformulate their menu offerings in some way, including sodium reduction or clearer food-handling policies to minimize risk of allergies. One small chain reported that carrying out nutritional analysis, on their own accord, had prompted them to reduce sodium, lower fat, and even switch to brown rice in their menu items. The same small chain suggested that smaller companies, in contrast to large ones, could more readily and feasibly adapt menus to provide nutrition information, since they were less embedded in complex supply chains. Several interviewees called into question the evidence on effectiveness of menu-labelling interventions to shape consumer behaviour.

The range of chains represented included different sizes, from large multinational firms to very small, local multi-site restaurant groups; and about 10 cuisine types (e.g., one restaurant group encompasses restaurants comprising four different cuisine types).

Policy consultation with restaurant associations

Meetings with the two provincial restaurant associations revealed that industry generally supports the provision of nutrition information to customers but does not support the display of such information on menus due to a perceived negative impact on business profitability as well as questions regarding the effectiveness of menu labelling on behaviour change. Associations articulated an industry truism that restaurants respond primarily to consumer demand and preferences, although some companies express a desire to be perceived as industry leaders, especially in health terms. The associations expressed a preference for disclosing information in non-menu formats.

DISCUSSION

The Ontario Public Health Standards, (23) which direct public health programs and service delivery in the province, identify "the provision of nutrition information in local food premises as one policy approach that supports healthy eating environments." The research findings described above reveal important stakeholder attitudes concerning menu labelling as an approach to altering the away-from-home food environment in Toronto.

As expected, Toronto residents commonly eat out and they place importance on being able to access healthy food when doing so. They also responded positively regarding their current and intended use of nutrition information on menus, to a greater degree than has been seen on previous Canadian surveys. For example, a 2008 national survey found that only 22% of people report looking for nutrition information when eating out. (4) Our results do confirm a 2011 public survey carried out for the federal government suggest ing that about 7 in 10 Canadians strongly support requiring fast-food restaurants to list nutrition information on menus. (24)

Alongside public support for menu labelling, this research confirmed competing values and predicted resistance to this approach from diverse industry actors. In existing literature, menu labelling is seen to be an imposition and an implementation challenge, particularly in terms of consistency of food preparation and variations in accuracy of nutrient information analysis methods. Independent restaurant operators certainly expressed challenges (in terms of time, costs and expertise) that are consistent with findings in the existing literature. (8,25-27) The interviews also indicated that large-chain attitudes reflect opposition to intervention by lower levels of government expressed by major industry actors such as the Canadian Restaurant and Foodservices Association.

About half of independent restaurant operators conceded that menu labelling would be good for business, though a majority would do it only if required, confirming that legislation requiring nutrition information disclosure would be more effective than voluntary measures. Despite low overall interest in menu labelling, positive views were uncovered among independents and small chains, revealing potential leverage points for local authorities. Interviewees indicated a willingness to stay on top of health trends and to respond to consumer demand by making changes to menu items. One small chain revealed the commitment and capacity of smaller operators to readily effect changes in purchasing and menu and recipe reformulation. This observation has informed menu-labelling pilot program design in other jurisdictions, such as Tacoma-Pierce County, (9) and yet is inconsistent with the argument presented by restaurant industry associations that independent operators face more operational difficulties in implementing nutrition information disclosure. Future research with smaller chains should take into account this subgroup's greater resemblance to independent restaurants (indeed many of the small "chains" in THEIS are independently owned), and further qualitative research would be valuable to elicit a full range of responses. Finally, there was a surprising amount of interest in a pilot program to test the needs of independent restaurants, indicating that a cohort might be engaged effectively as early adopters for a menu-labelling policy or program in Toronto. This group of early adopters has formed a starting point for the next phase of industry engagement.

This research had several limitations. Public survey response rates were low for the core sample. Because the core sample was significantly under-represented for younger adults in particular, the over-sample survey was conducted to compensate for this issue. The completion rate for the independent restaurant survey was also low, but not unexpected given time constraints for small business operators and the time of year. Feedback from the market research firm suggested that computer literacy issues may have played a role in the response rate. The unexpectedly high level of interest in the pilot likely indicates that those operators who are less supportive of or less interested in menu labelling were less likely to participate in the survey. While the sample size for in-depth interviews was small, conceptual saturation was achieved with the group of large-chain restaurant decision makers, particularly in light of information gathered from consultation processes with regional associations.

Study strengths included the multi-pronged, mixed methods approach to exploring stakeholder views and the health department's partnership with academia, as seen in other jurisdictions, e.g., King County. (28) Although Toronto is not the first jurisdiction in Canada to explore menu labelling in-depth (e.g., British Columbia as noted above), the diverse population and equally heterogeneous and large restaurant community (Toronto has more restaurants than does the entire province of British Columbia) requires a unique, measured, and collaborative approach. Our research has indicated that there is a base of public support for and intended use of nutrition information displayed in restaurants. That at least a minority of restaurant operators are willing to explore how best to address this provides a firm foundation for future policy work at the local level.

Owners and operators of food premises are critical stakeholders in public health interventions to promote healthy food environments outside the home. Local businesses are essential for community economic development and the attitudes of restaurant operators are a key municipal policy concern. As such, it is important that public health staff find ways to work effectively in consultation with local food industry actors in planning and implementing menu-labelling initiatives. Related public health interventions of a regulatory nature dealing with consumer right-to-know and information disclosure have benefited from such interactions. (29,30)

Finally, municipal governments and local health authorities have been identified as important agents in leading policy change for healthier food environments. (1,31) Our research offers relevant background considerations for other cities developing healthy public policies for food and healthy eating at the local level.

CONCLUSION

This research supports earlier findings indicating a foundation of public support for menu labelling and restaurant industry opposition. Nonetheless, we found evidence of leverage points to potentially increase the feasibility and desirability of menu-labelling interventions among restaurant operators, particularly with the provision of dedicated public health supports. As menu-labelling interventions proceed in Canadian and US jurisdictions, it will be valuable to increase the range of evidence on the conditions under which restaurant operators can optimally engage as stakeholders in this health intervention, given their importance to local economies, and in order to make menu labelling a win for consumers, public health, and foodservice businesses.

Conflict of Interest: None to declare.

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Received: October 22, 2012

Accepted: March 13, 2013

Catherine L. Mah, MD, PhD, [1,2] Loren Vanderlinden, PhD, [1,3] Dia Mamatis, MA, [3] Donna L. Ansara, PhD, [3] Jennifer Levy, PhD, [3] Lisa Swimmer, MHSc, RD [4]

Author Affiliations

[1.] Dalla Lana School of Public Health, University of Toronto, Toronto, ON

[2.] Food Policy Research Initiative, Centre for Addiction and Mental Health, Toronto, ON

[3.] Healthy Public Policy Directorate, Toronto Public Health, Toronto, ON

[4.] Chronic Disease and Injury Prevention Directorate, Toronto Public Health, Toronto, ON

Correspondence: Dr. Catherine L. Mah, Centre for Addiction and Mental Health, 33 Russell Street, Toronto, ON M5S 2S1, Tel: 416-535-8501, ext. 4665, Fax: 416-595-6068, E-mail: catherine.mah@utoronto.ca

Table 1. Public Survey: Socio-demographic
Characteristics of the Sample

                       n *    (%)

Socio-demographic
Characteristics

Total sample           1699    -100

Sex

  Male                  642   -37.9
  Female               1053   -62.1

Age group (years)

  18-29                 387   -22.8
  30-39                 339     -20
  40-49                 270   -15.9
  50-59                 258   -15.2
  [greater              445   -26.2
    than or
    equal
    to]60

Highest level of education

Less than high school   102    -6.1
High school diploma     428   -25.4
Post-secondary         1155   -68.5

Household income

  $0-$39,999            331   -19.5
  $40,000-$79,999       353   -20.8
  [greater              508   -29.9
    than or
    equal
    to]$80,000
  Refused/Don't know    507   -29.8

Note: Data are from the 2011 Interim Toronto
Health Survey. Data are unweighted.

* Numbers may not add up to 1,699 due to missing data.

Table 2. Independent Restaurant Survey:
Characteristics of the Sample

                                 n     (%) *

Restaurant and Cuisine
Characteristics

Total sample                     256      100%
Restaurant type
  Fast-food                       26   (10.2%)
  Take out or delivery            28   (10.9%)
  Sit-down or full-service       134   (52.3%)
  Coffee shop or cafe             36   (14.1%)
  Pub-style                       19    (7.4%)
  Catering-focused                 6    (2.3%)
  Other                            6    (2.3%)
Busiest meal of the day
  Breakfast                       20    (7.8%)
  Lunch                           88   (34.4%)
  Dinner                         118   (46.1%)
  Snack time/Dessert              12    (4.7%)
  All of the above                18    (7.0%)
Number of seats in restaurant
  1-50                           155   (60.5%)
  51-100                          51   (19.9%)
  101-150                         21    (8.2%)
  151-200                          9    (3.5%)
  201+                            20    (7.8%)
Annual revenue
  <$50,000                        65   (25.4%)
  $50,000-<$100,000               31   (12.1%)
  $100,000-<$150,000              22    (8.6%)
  $150,000-<$200,000              10    (3.9%)
  [greater than or equal to]     114   (44.5%)
    $200,000
  Refused                         14    (5.5%)
Cuisine
  Canadian                        49   (19.1%)
  International                   29   (11.3%)
  Pub food                        18    (7.0%)
  Chinese                         15    (5.9%)
  Italian                         15    (5.9%)
  Sandwiches                      15    (5.9%)
  Japanese                        13    (5.1%)
  Indian                          11    (4.3%)
  Thai                             9    (3.5%)
  Korean                           8    (3.1%)
  All other identified            71   (27.7%)
  cuisine types, combined

Median cost of an average meal across all
restaurants = $9.70

* Numbers may not add up to 100% due to missing
data.